NPIMap

Organization Active NPI

Destiny Sober Living

  • Addiction (Substance Use Disorder) Counselor
  • Phoenix, AZ
National Provider Identifier
1104365287
Registry record updated Feb 22, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Addiction (Substance Use Disorder) CounselorTaxonomy code 101YA0400X
License
BH3285 Issued in AZ
Legal business name
DESTINY SOBER LIVING
Practice address
5306 N 17TH Ave
Phoenix, AZ 85015-3035
Phone
(602) 249-6674
Fax
(602) 926-0590
NPI assigned
Feb 22, 2017
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 22, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Kathleen Bynum, LPC
Title
Executive Director
Phone
(602) 249-6674

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Addiction (Substance Use Disorder) CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YA0400X BH3285 AZ Primary
Mental Health CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YM0800X BH3285 AZ
Professional CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YP2500X AZ

Addresses

Primary practice location

5306 N 17TH Ave
Phoenix, AZ 85015-3035

Mailing address

5306 N 17TH Ave
Phoenix, AZ 85015-3035
Phone (602) 249-6674

Other identifiers 3

IdentifierTypeStateIssuer
439095MedicaidAZ
148801MedicaidAZ
925164MedicaidAZ

National Provider Directory

National Provider Directory
Tax ID family
Destiny Sober Living II Carver Ranch6 organizations share this tax ID, including this one

Other organizations with this tax ID 5

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1487721600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1487721600000",
    "number": "1104365287",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5306 N 17TH AVE",
            "city": "PHOENIX",
            "state": "AZ",
            "postal_code": "850153035",
            "telephone_number": "602-249-6674",
            "fax_number": "602-926-0590"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5306 N 17TH AVE",
            "city": "PHOENIX",
            "state": "AZ",
            "postal_code": "850153035",
            "telephone_number": "602-249-6674",
            "fax_number": "602-926-0590"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DESTINY SOBER LIVING",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-02-22",
        "last_updated": "2017-02-22",
        "status": "A",
        "authorized_official_last_name": "BYNUM",
        "authorized_official_first_name": "KATHLEEN",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "602-249-6674",
        "authorized_official_credential": "LPC"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "AZ",
            "license": "BH3285",
            "primary": true
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Mental Health",
            "state": "AZ",
            "license": "BH3285",
            "primary": false
        },
        {
            "code": "101YP2500X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Professional",
            "state": "AZ",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "439095",
            "state": "AZ"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "148801",
            "state": "AZ"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "925164",
            "state": "AZ"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Phoenix, AZ

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 22, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.